Challenging Dogma - Spring 2009

Thursday, May 7, 2009

A Intervention for Smoking Prevention and Cessation Among Adolescents-Brita Reed

Although the prevalence of cigarette smoking has decreased substantially in the U.S. over the past thirty years, less impact has been made on the incidence of the initiation, or the prevalence of the continuation, of smoking among adolescents. The current inability among public health researchers to not only fully understand adolescent smoking cessation, but also to find effective intervention methods is unfortunate since implementation of smoking cessation interventions in adolescents is well justified in light of the devastating consequences of smoking on health. For example, in 2000, smoking-related illnesses claimed more American lives than alcohol, motor vehicle accidents, suicide, homicide, AIDS, and illegal drugs combined. (

Among adult populations, numerous studies employing the Trans-Theoretical Model (TTM) have shown that the behavioral and cognitive processes of change, as well as an understanding of decisional balance (i.e., how individuals weigh the pros and cons of their behavior change) and temptations (i.e., individual’s beliefs about their behavior change), can aid in public health interventions regarding smoking cessation (Prochaska & DiClemente, 1983). Employing TTM as the basis for Motivational Interviewing (MI) in adults, for example, allows the interviewer to address behavior change in smokers that enhance readiness to change, increase smokers perception of the negative consequences of smoking, decrease smokers perception of the positive benefits of smoking, and assess the obstacles to moving forward to a higher stage (Sommers-Flanagan, & Sommers-Flanagan, 2003).
The use of TTM in public health interventions concerning smoking initiation and continuation among adolescents, however, has produced disappointing results. This is disconcerting in that, for both males and females, smoking initiation is primarily an adolescent behavior and relatively few people begin smoking after age 21(Lewis, 2002). Many adolescents who begin to smoke are unaware of how difficult it often is to stop smoking.

Foundation of the Proposed Intervention: Erik Erikson’s Psychosocial Stag of Adolescent Development
Erik Erikson’s epigenetic formulation of the stage-theory of psychosocial development in the 1950s and 1960s was loosely based on Freud’s psychosexual stages of development which had been published decades earlier. Freud, a psychoanalyst, thought that personality was essentially completed by the end of early childhood. Erikson was a developmental psychologist; as such, he was convinced that personality continued to develop across the life span.

According to Erikson, there are eight stages of psychosocial development beginning with infancy’s stage of trust versus mistrust and ending in old age’s stage of integrity versus despair. Completion of each stage helps to ensure mental well-being. Erikson’s stage of identity-versus-role-diffusion, which begins at puberty and extends through adolescence (Erikson, 1950), readily lends itself to the creation of a novel intervention to mitigate both the incidence of initiation and the prevalence of continuation of smoking among U.S. adolescents.
Eriksonian theory states that the formation of identity is the vital task of the late adolescent years and is unique to the adolescent stage of development. Failure to successfully work through identity issues may inhibit further healthy personality growth (Erikson). Erikson has a rich sense of the complex relationships between the adolescent and the surrounding culture; indeed, he is certain that culture molds an adolescent’s identity as the individual psyche is generated and shaped with the requirements, values, and sensibilities of a particular cultural context (Mitchell & Black, 1995).

For Erikson, adolescent identity occurs at a time of transition between childhood and adulthood, at the point of intersection between the individual and the social world. According to Erikson, adolescents in the stage of identity-verses-role-diffusion are primarily concerned with how they are seen by others and how that view compares to their own self-conception (Erikson, 1950). To this end, they temporarily over-identify, to the point of complete loss of their own identity, with “the heroes of cliques and crowds (228).” This over-identification serves an important purpose: It aids the adolescent in his/her attempt to arrive at a definition of his/her identity by projecting his/her diffused ego images on one another and, by seeing these ego images thus reflected, gradually clarified.

Proposed Intervention Informed by Eriksonian Theory: Peer-Led Group Therapy
Eriksonian theory suggests that an intervention that is socially-based, rather than individual interventions such as TTM, may be more effective in reducing smoking among adolescents. I propose an intervention of peer-led group therapy which focuses on the meaning of smoking to the group participants. The group will be comprised of adolescent smokers, some of whom are contemplating smoking cessation. In addition, adolescents who are contemplating initiating smoking will also be in the group.
This intervention will explore the psychosocial aspects of adolescents through an understanding of their need to explore identities, including the identity of being a smoker or a non-smoker. As such, it will addresses adolescents’ feelings, attitudes, and experiences concerning using tobacco, as well as not using tobacco. Who do they think they are in the eyes of their friends, parents, and teachers if they smoke or do not smoke? What statement does their decision to smoke or not to smoke make to the world about who they are? Is smoking or not smoking congruous with the identity they are developing as young adults? In sum, these sessions attempt to aid the adolescent who is smoking, as well as the adolescent who is considering the initiation of smoking, to strive to fully understand the meaning of smoking in his/her life.

The Value Added of the Proposed Intervention over TTM: Understanding Risk-Taking in the Development of Identity in the Adolescent
These therapy sessions will help the adolescent to understand his/her own risk-taking tendencies. According to Erikson, adolescence is a time of experimentation: As young people seek to define and solidify their identity, they often try on many identities (Erikson, 1950). Experimentation, therefore, serves the purpose of testing whether particular behaviors are congruent with the adolescent’s self-image (Lewis, 2002). Some behaviors are engaged in to represents to others the way the adolescent wants to be identified. Seigel reminded us that, in certain populations, it is the potentially destructive nature of high-risk behaviors that may motivates and supports the behavior (Seigel & Doner, 2004).

These therapy sessions will aid the adolescent to understand what the risky nature of smoking, which is known to them, adds to their inchoate identity. Many researchers believe that risk-taking behaviors may be normative for this adolescent period of identity formation as the adolescent explores identity options (Lewis, 2002). In fact, research suggests that some experimentation with smoking may actually characterize the psychologically health adolescent (Lewis). This may help explain why interventions which focus on educating adolescents on the short and long-term health risks of smoking have not made significant impact on adolescent smoking initiation or cessation. The problem, of course, is that many adolescents are making the decision to begin smoking or to continue smoking without fully comprehending the power of the addiction involved.

Value Added of the Proposed Intervention Over TTM: Understanding Differences Between Adolescent Smokers and Adult Smokers
This intervention is based on the Eriksonian premise that the period of adolescence is a specific and unique stage of psychosocial development in the life of the individual. It helps to explain the folly of taking an intervention, such as TTM which has been shown to work for adults, and assume that it works for adolescents. Although Eriksonian theory predated neuroanatonical research employing technology such as fMRI, he seemed to know intuitively that the adolescent brain functioning was different from that of the adult. Thus, he postulated a specific stage of development unique to the adolescent brain which resolved in young adulthood. We now know that adolescents have less frontal lobe conductivity than adults; consequently, they have less executive functioning, and more difficulty in goal setting, controlling impulsive behavior and imagining the future. My intervention will specifically target these nascent abilities in adolescents and allow them to improve these skill sets at their own pace with the help of their peers.

Value Added of the Proposed Intervention Over TTM: Understanding the Adolescent’s Social World
Because Christakis has shown us that smoking is a network phenomenon (Christakis, 2008), my proposed intervention involves groups that not only comprise peers, but also are peer led. Erikson understood the importance of peers to the identity development of adolescents. My intervention uses the Eriksonian notion that adolescents overinvest themselves in their peers during this stage of development.
The importance of the nested social contexts of the adolescent, which include an individual’s family, peers, school, neighborhood, and wider social culture, needs to be addressed in any intervention that concerns adolescent smoking. My proposed intervention aids adolescents in exploring the influences of these constituents on their decisions concerning smoking. It also regards the media’s attempts to influence the developing identity of adolescents as it develops market niches for tobacco companies.

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